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All parents wish for a child with an easy temperament, who is easy to manage, always agreeable, and especially one who, from a very early stage, sleeps through the night. Of course, this is not the reality. Just as there is great variation in the temperaments and personalities of different children, so is there great variation in children’s sleep habits. Often these are due to intrinsic elements in the child’s makeup. After a while, however, what is far more striking than these biological differences in children with sleep problems are the behaviours that the parents of these children have in common. Virtually without exception, parents of children with sleep problems will themselves have slipped into habits which serve to encourage and reinforce the problems in the children.

Many of a child’s ongoing problems are actually contributed to by parental intervention. For example, a child who is rocked to sleep every night will come to depend on this, and will not go to sleep without it. The child also soon learns that the rocking will cease as soon as he falls asleep, and will therefore fight to stay awake, thus making him even more irritable and difficult. Similarly, a child who is used to parents coming into the room if he wakes and cries or calls out during the night will come very quickly to depend on this. Many young children have thus never learnr how to get themselves off to sleep, either at the time of going to bed or else when they wake up during the night.

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Make sure the heart has stopped before doing this. The pressure you exert on a patient’s chest — adult or child — may do damage. Some doctors think that external cardiac massage should only be done by someone trained in its procedure. However, YOU may have to use it in an emergency.

In a child, the most common causes for a cardiac arrest are drowning, electrocution and suffocation. In an adult, a heart attack is probably the most common. It may also result from poisoning or from gassing.

The signs of cardiac arrest are: loss of consciousness; the patient has gone blue or is pale; there is no pulse; the breathing has stopped or there may be some gasps for a while; the pupils of the eyes dilate and do not respond to light.

The heart is a pump, pumping blood to all the tissues in the body. The aim of treatment is to start this pump again by compressing the heart between the breastbone and the backbone.

Act swiftly, for if the brain is deprived of oxygen for longer than 3-4 minutes, irreversible damage may result.

Lie the patient on a hard, flat surface. Kneel at the side of his chest; tilt the head back to open the airway.

For an adult, place the heel of the hand on the lower part of the breastbone, or sternum, and cover it with the other hand. Rock forward and press down firmly on the breastbone — not on the ribs. The chest wall in an adult should move 2Óã-5 centimetres (1-2 inches).

Do it gently the first few times to assess the resistance of the chest wall. For an adult, keep it up at the rate of 60 a minute. For a child, use only one hand (two fingers for an infant), but increase the rate to 90 a minute. If someone else is present, get them to do mouth-to-mouth resuscitation at the same time as you do cardiac massage. One breath to every five pushes on the chest. If you are alone, you will need to do both actions yourself. Two breaths for every 15 pushes on the chest.

Check to see whether your work has any effect. The pulses will return, the color will improve and the pupils of the eyes will constrict.

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Some proteins are broken down, in the body, and uric acid is formed. This substance is normally present in the blood and is excreted by the kidney. In gout, there is either an over-production or an under-excretion of uric acid. In some, there is a combination of both.

Uric acid builds up in the blood and is deposited as urate crystals in joints and the tissues around them. Urates may also be deposited as gouty tophi in other tissues, such as the ear or around the elbow.

The first indication is usually an acute arthritis. In most cases this involves the big toe, but any other joint may be involved. Occasionally, several joints are involved at the same time.

The pain comes on suddenly and is severe and throbbing. The joint is usually swollen and the skin overlying it is hot, reddened and shiny. The whole area is tender, and even light pressure on the skin is painful. Fever may accompany the attack. Unless treated, each such attack may last from five to seven days.

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These cause the endometrium to build up to form a soft, thick, spongy tissue in which the fertilised ovum can implant and develop into a child.

When, as in most menstrual cycles, conception doesn’t occur, this thick layer of tissue is shed with some bleeding.

When the womb is removed, a woman no longer has periods nor can she become pregnant.

In the past, a partial hysterectomy was common. This removed the body of the womb but left the cervix in place.

This was done because it was an easier and smaller operation for the woman and did not disturb the anatomy of the vagina.

This operation is rarely done now because it leaves the cervix and leaves the woman still vulnerable to develop cancer of the cervix. This cancer is second only to cancer of the breast in frequency in women.

The operation can be carried out through a cut made in the abdomen or by operating through the vagina, so there is no outside cut.

Which approach is used depends on what is wrong with the womb, how large it is and what other procedures are carried out at the same time. It is rarely due to the whim of the surgeon.

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Jaundice means the skin and the whites of the eyes turn yellow. All degrees may exist, and often it is so light as to be barely detectable. It invariably indicates liver disease. Generally speaking, liver disease (as occurring in adults) is quite rare in infants and children. The free use of alcohol is one of the major reasons why so many adults are prone to disorders of this vital organ; fortunately, infants have not yet learnt of this beverage. Some unwise mothers who imbibe freely during pregnancy give birth to severely damaged children (mentally and physically) who suffer from the so-called foetal alcohol syndrome—often the babies perish soon after birth.

Infectious hepatitis is a virus infection of the liver which can produce serious illness, but it is usually mild and recovery is common.

Jaundice of the newborn

Jaundice of the newborn, also called physiological jaundice, occurs commonly in normal babies. In fact, it is claimed that about 10 per cent of babies show this. It comes on during the first week of life, but usually not before the first 36 hours. It vanishes just as rapidly after the first week, leaving no aftermath.

The red blood cells of the body are continually being manufactured and broken down. When destroyed, they yield a product called haemoglobin, and this is disposed of by the liver. A baby’s liver is not always geared to cope with the fairly large amounts it has to dispose of in early life, so the by-products build up as a substance called bilirubin.

Other forms of jaundice

If the baby is jaundiced at birth, or if physiological jaundice persists beyond a week, the doctor will seek out other causes. It is a cardinal sign of liver disease, and the cause must be found. If large amounts of bilirubin (the material that causes the yellow discoloration) are allowed to remain in the blood, serious and permanent adverse effects are probable. A condition called kernicterus may take place. This comes from the Greek words meaning kernel (of the brain) and icterus (jaundice). Staining and damage of the vital brain centres may occur. It may cause death at worst, or it may leave the infant with permanent brain palsy, deafness and mental retardation.

A serious and fairly common cause of this in bygone days was the so-called haemolytic disease of the newborn, caused by the blood group Rh factor. It occured in some women who were Rh negative producing a Rh positive child, and whose systems had been sensitized by an Rh baby previously. With each subsequent Rh pregnancy, the condition became more severe and serious. Total blood transfusions were carried out on affected babies in an attempt to save them, and many were highly successful. However, with the ready availability of Rh immunization for these women, given within 72 hours after producing an Rh positive child, this risk has now largely vanished.

There are various other causes but these come within the orbit of obstetricians and paediatricians caring for babies when they are born. The condition is usually picked up and treated at once.

Hepatitis A (infectious hepatitis)

The more common variety is also called Hepatitis A, or viral hepatitis. It is more likely in adults, but may occur in children and infants. It is caused by a virus and is believed to be transmitted by flies which infect food, but there may be other ways of contamination as well.

It takes about two to six weeks for the germ to incubate and produce symptoms. Often it is sub-clinical, meaning no obvious symptoms occur. The child merely feels off-colour. Frequently, as the liver becomes infected, the cells swollen and the normal flow of fluids through the system affected, jaundice occurs. This may be mild, with only a staining of the whites of the eyes. Or it may be more pronounced, and the whole body becomes an obvious yellow.

It may have a rapid onset, with fevers, chills, malaise, lack of appetite, vomiting, headache, and aches and pains all over the system. Jaundice of the eyes and skin may occur; and if so, the skin often becomes very itchy, the child starts scratching and may break and abraid the surface. Sometimes the lymph glands of the body swell and become tender. These may be in the neck, under the jaw, in the armpits and groin. Often the liver and spleen also swell and are tender. The liver, in the right-hand side of the abdomen, may be felt protruding from under the rib cage. On the left-hand side is the spleen, a large organ associated with blood production.

An infection with jaundice occurring during childhood, and with the symptoms listed, is most likely infectious hepatitis. However, see the doctor for a confirming diagnosis and be guided by the doctor’s recommendations for treatment.

Treatment of hepatitis A

Most cases are mild and may be managed at home. Children prefer to stay in bed for the first few days at least, and maybe longer. It depends on how quickly they start to recover.

There are no restrictions on food intake. Giving a good nutritious diet is advisable, if the patient is inclined to take this. Fat-containing foods may be unacceptable because the patient experiences nausea. (The old idea of withholding fats for medical reasons no longer applies.) All the child’s usual foods may be given. However, from a practical side, small portions of attractively served foods along the lines of the patient’s favourites are probably the best idea. Plenty of fluids are recommended, for these help to wash toxins and debris from the system and always help in recovery of any infection.

Usually there is no medication given, for the liver would then have to cope with drugs and it is already inflamed and battling itself. Additional vitamins (especially the vitamin B series) can help strengthen the liver.

This infection is usually self-limiting, and recovery is the usual result. Most patients suffer minimum or no jaundice, but sometimes there is major and serious yellowing which may indicate a severe degree of the disease.

If one member of the family has infectious hepatitis, a good deal of protection for the other members may be gained by an injection of gamma globulin. The doctor arranges and administers this.

Hepatitis B (serum hepatitis)

Today this is better known as Hepatitis B, and it is also caused by a virus. In children it is much rarer. It is transmitted by infected blood and for this reason it occurs in persons receiving injections with needles previously used by an infected person—so is more probable in drug addicts. Hepatitis B used to occur occasionally after blood transfusions, but now, with screening tests for blood, this is unlikely in this country; the infection is more common overseas, especially with commercially bought blood. However, it is claimed that the virus can also be transmitted via breast milk and various other body fluids. It is worth noting that many cases have occurred in young people after they have been tattooed and also in girls (often children) after they have had their ears pierced; on checking, it has been found that the instruments used were not completely sterilized. Now that pre-sterilized studs are widely used for ears, the incidence has been reduced, but parents should still be careful to check that this is so if their children intend having their ears pierced.

It may take six months or more for symptoms to develop from the time of infection. The illness is serious and many deaths have occurred.

Treatment of hepatitis B

It is essential that treatment be under full medical supervision. This is best carried out in a major hospital, where clinics are geared for diagnosis and treatment of this unfortunate illness.

For any case of obvious jaundice, treatment must be under proper medical supervision. Although certain cases may be treated quite satisfactorily at home, proper diagnosis in the first place is essential. After this, it is important to be guided by the doctor’s suggestions. The advice offered in this section is to be used only as a general guide, to give some idea of the nature of therapy that will probably be recommended. The only medication, if any, to be taken is that prescribed by your doctor. Drugs given are usually minimal, and then only for the more serious forms of the disease. Parents should not self-medicate, for this could aggravate the disorder and prolong convalescence.

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‘Ideally the less medication you take the better, for it is often transmitted to the baby via breast milk. But make certain you take only medicine that is prescribed by me, as your doctor. Small amounts of tea, coffee or even alcohol are fairly innocuous. But smoking is bad news, and I strongly recommend any young mother who smokes to stop right now. Ideally, she will have stopped before she became pregnant, for the hazards during pregnancy are high. Poisons may be transmitted via the milk, and the baby’s system is not geared to the toxins in cigarette smoke. A lot of research confirms this.

‘Karen, a close relationship between you and your baby is the ideal. Although this is best achieved when breast feeding, it can also become established with artificial feeding. It is best to weigh all options, to try breast feeding to begin with and persist with it for as long as practical,’ I said.

‘Does demand feeding continue right throughout the feeding business?’ Karen asked.

‘Very soon your baby will establish her own alarm system and will settle down to regular feeding schedules. So whether you feed by the clock or on demand, it makes very little difference long term. Many arguments are still being waged about the benefits and disadvantages of each system—in reality it matters little. If the baby is gaining weight and obviously growing normally, the method in use is satisfactory. If there is any doubt, have her weighed at the clinic and you will soon discover if there is anything wrong.

‘There is no need to let the baby rule your life, incidentally. So many mothers tire themselves out needlessly by letting the new arrival rule not only their own life but the total running of the home. This is foolish. Stick to sensible time schedules, but you must live your own life at the same time.

‘At about three months, the baby will sleep right through the night, and the tiring night feeds will come to an end. You can then give a sigh of relief, for this makes life so much easier for everyone.’

‘What are some of the pitfalls of feeding Joanna? I’m sure there are many I will discover,’ Karen said.

‘Yes, feeding difficulties will certainly happen. Babies that are highly strung may present the greatest number; they tend to demand a lot of attention. Wind, colic and bowel upsets are common in the superactive baby. Many are difficult when their nappies are wet or if they are left alone for a while.

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